Understanding Addiction

Some of the comments following my last post asked the same question — and it needed to be asked: How might you apply this perspective? What kind of treatment program would embody these concepts? Let’s get concrete…how would it work?

I more or less ended that post with the following proclamation (copied here, in part, from that post):

Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because…there is no line-up at the door… Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future…[while the desire knob is turned up to max.]

Or, to put it in terms of the biology, “what will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change.”

But you often need other people — either one person or a group of people — to hold those elements in place, to help make it happen. Which is why treatment must be interpersonal if it’s to have any chance of working.

So, at the end of the book, and here in today’s post, I provide an example that captures the critical importance of striking while the iron is hot — when desire is turned up high and synched (for the moment) with the vision of a future self free of addiction. It’s a radical treatment initiative that uses “other people” at the grass roots level, to hold the pieces together before the iron cools. And it’s been inspired and shaped by my friend Peter Sheath, a former addict and senior associate of a consulting group for service delivery in the U.K. Thank you, Peter, for inspiring me with your description of this exciting venture.

The city of Birmingham (the second largest in England) is investing massively in this pilot program, designed to provide help for addicts at the very moment when their desire for change is ignited. Treatment nodes are distributed across the community, through sites that are most available to addicts in their day-to-day lives. Shopkeepers, including newsagents, bakers, butchers, and pharmacists, are trained in brief interventions. Participants’ shops display an ROR (“Reach Out Recovery”) sticker on the front window, so that addicts immediately see that they are “recovery-friendly” and ready to help. People come in off the street, perhaps buying a loaf of bread at the same time, and say “I’ve had enough! I’m ready to quit!” Then the shopkeeper tells them they’ve come to the right place, takes a quick inventory, and advises them on what to do next. “Hey, reduce your drinking a bit, and then pop by and talk with me this afternoon or tomorrow.” Or, in more severe cases, “I won’t be able to work with you but I know somebody who can.” People can be referred to “peer mentors” who will show up the following day to help them with difficult issues such as detox and other medical matters. Even taxi drivers have been recruited, so that someone en route to score can throw up his hands and call it quits without that incentive getting lost in translation.

Obviously the community needs to be motivated to make this happen. But that’s a boon in itself, because it recasts the problem of addiction as everyone’s problem, not the burden of the individual alone. (Shades of Rat Park!) So the support is there, the immediacy is there, and the infrastructure is built and organized without any religious or medical axe to grind. And it’s free. The funding comes from the city, not from the addict’s already-stretched family.

I see this as a highly creative approach. Whether it will work as well as we hope remains to be seen. The project is inspired by intuitions about the mercurial nature of desire and the power it bestows on our most essential plans — an intuition that fits what we know of the neurophysiology of addiction. More generally, the project exemplifies the innovation and insight that can sprout when the disease model is retracted and a fresh perspective, free of orthodoxy and special interests, is allowed take in its place.

…by April Smith…

What’s HAMS? If you don’t know about it yet, this guest post says it all: HAMS stands for Harm Reduction, Abstinence and Moderation Support. I’ve recognized and admired this organization for years, and I’m delighted to have April tell you more about it.

…………………………

I went to rehab at age 40 after a horrific crash that landed me passed out on a busy street in Philadelphia.  I don’t rehash my story in public, but things were so bad that I was grateful that my parents made the huge financial sacrifice it took to send me to one of the oldest and most respected 12-Step rehabs in the country.

I dutifully did everything I was told, announced to everyone I met that I was an “alcoholic,” and earned the nickname “Recovery Supergirl.” Surprising for a Yale grad who had succeeded at everything? Maybe — until a series of traumatic events and alcohol-fueled relationships eventually landed her facedown on the concrete.

Though outwardly I was the soul of enthusiastic compliance with my treatment, the questions were brewing.  I didn’t think that character defects and self-centeredness had caused my alcohol problems.  I had no interest in spending  my life confessing my sins to strangers.  And I wasn’t convinced that a lifelong abstinence from any mood-altering chemical (except caffeine, sugar and nicotine!) was the only answer.

From reading Marc’s Memoirs of an Addicted Brain, I went on to read the many others who have brought to light real science and common sense about addiction: Johann Hari, Carl Hart, Stanton Peele, and others.  I started writing comments on Marc’s blog, and Marc asked me to turn one comment into a guest post.

A man named Kenneth Anderson found the post and friended me on Facebook.  He is the Founder and Executive Director of a group called Harm Reduction, Abstinence and Moderation Support (HAMS) for Alcohol.   HAMS is a worldwide organization with a vibrant, supportive and non-judgmental Facebook presence, live chats, a forum, and useable, evidence-based tools.

I joined HAMS in a moment of crisis.  After about a year of complete abstinence after rehab, I decided to try drinking moderately.  I sat down at a bar I had once frequented, had a glass of wine, ordered a second and drank only half of it before pushing it away and heading home.

My then-boyfriend freaked out: “You’re drinking again!  You know you can’t drink because you’re an alcoholic!”

The absurdity of it hit me like a bottle of beer smashed over my head.  I had a glass and a half of wine.  Nothing happened.  The world did not end.

In HAMS, I found a community that supported me, no matter what my alcohol choices were.  We support all goals, not just abstinence.  We do not require or recommend that people who have problems with alcohol stop drinking forever.  We don’t require anything, other than that members treat each other with respect and not judgement. We support abstinence (a word we prefer over “sobriety,” as “sober” has moral connotations), moderate drinking, and safe drinking.

It wasn’t long after I started to work with Kenneth that I became the leader of HAMS for Women, a subgroup of women who are trying to change their drinking.  In HAMS for Women, we refer to each other as “ladies,” because women who drink have too often been described by derogatory names — anything but ladies.  We carefully moderate the group to make sure that shaming, blaming, and judgmental comments are kept off.

We don’t just talk about alcohol, though.  We talk about spouses, children, and we post pictures of our pets!  We’ve had extremely sad moments: the day we learned of the death — from cirrhosis — of a woman we had seen through crisis after crisis as her abusive husband kept pushing things just a bit further, all the while keeping her too drunk to work and make a living. We exchange stories we dare not tell in public. In this group we find nothing but love and support.

For me, HAMS has been a critical part of rewriting my identity.  The label “alcoholic” seemed to erase everything I had been before, and everything I might be in the future.  No matter what I did, even when I didn’t drink, I felt shame.  HAMS has taught me that the content of my bloodstream is not the content of my character.  Now my identity is not defined by my relationship to alcohol.  I am not an “alcoholic.”  I am April Wilson Smith.

Many HAMS members learn to successfully moderate, using HAMS tools such as counting your drinks and deciding on a limit in advance. Contrary to the (irrational) idea — promoted by AA and the popular press — that one drink will ruin your life, HAMS members are often able to achieve moderation, even if they had serious problems with alcohol before.  Many choose to abstain altogether, a choice we applaud as well. Our motto is, “Better is Better!”

I recently had the opportunity to interview Kenneth for Filter Magazine.  See the full interview here.

HAMS has just published an e-book, priced at $0.99, relating the stories of our members: their struggles and successes.  We hope you’ll pick it up and check us out on Facebook.  Here’s what Marc has to say about the book — an endorsement that joins praise by Maia Szalavitz, Stanton Peele, Johann Hari, and others.

“Through these moving personal stories, we learn not only how HAMS works but how addiction works. And we learn that overcoming addiction doesn’t have to adhere to a rigid program or philosophy. HAMS succeeds because it connects with people who drink, on their own terms, respects their goals and wishes, recognizes their strengths and supports them where they need and want support. These little memoirs are as varied in style and substance as the individuals who wrote them, but they converge on themes that just don’t go away, including the inadequacy of AA for many who drink, despite its value for some. Intimately told, both raw and articulate, these memoirs reveal how people struggling with addiction can help each other through sensitivity and generosity rather than judgment and dogma.”

I had the pleasure of interviewing HAMS members for the creation of this book, and I saw the full range of improvements in their approach to drinking, without the aid of a Higher Power or even a therapist.  They are living proof that all choices, not just abstinence, can work.

Better is better!

Just got back from the US the day before yesterday, and I’m mostly trying to reset my body clock, nine hours ahead of where it was in California, or maybe behind, or is it ten hours with Daylight Savings…? I haven’t quite got it worked out.

Anyway, just this morning it occurred to me that I forgot to let you guys know that the Great Debate is finally available on YouTube. Here it is. Thanks to Shaun Shelly for crunching all those gigs into something relatively bite-sized (pun intended?) and doing whatever he had to do to dampen background noise. The sound quality isn’t bad for a talk in a theatre.

I’ve got lots more to share with you from my time in the US. I continue to love Americans, loathe their politics, and try to stay afloat in that peculiarly American miasma made of equal parts hope and despair. The societal challenges are so huge. How will they ever be resolved?

But the biggest challenge I witnessed, up close, in my face, was the suffering and anxiety, the attempts to come to grips with mortality rates and the loss of friends and loved ones, that continue characterize the opioid epidemic. Overdose deaths are still the leading cause of death in Americans under 50. And suicide is a close second (in some reports), exacerbated not only by substance use but prevalent during periods of abstinence. The system (if we can even call it that) is completely broken.

I gave a talk in Long Island and did some version of my usual spiel about the “disease” label and the problems it creates, in our scientific and social understanding of addiction and in the twisted ethos of a treatment industry powered by profit and offering little more than a quick fix for a problem with deep roots. But the day after my talk, something changed. I sat on a panel with the program directors of several community and state organizations tasked with helping addicts survive and, ideally, stop using. The meeting and discussion were hosted by THRIVE, a community-based organization  (note: this is not the for-profit rehab by the same name) that describes itself this way:

So if that’s what we have to call it to get people what they need, in a country whose healthcare system is almost entirely lacking in rationality or compassion, then that’s just the way it is.

In my psychotherapy (and chats, consultations, etc) with people in addiction, I combine skills I’ve picked up over 35 years studying clinical psychology, developmental psychology, psychoanalysis, and neuroscience. But it’s not enough. I need retooling.

I’ve developed some good intuitions about how to do psychotherapy…mostly by doing it, putting theory into practice. And I can be effective with people in addiction partly because I’ve been there myself. I know I’ve helped people transform their addictive habits. I’ve had clients who’ve quit, cut down substantially, or who continue to use or drink without a sense of desperation or compulsion. I’ve helped people discover or rediscover how to like themselves, forgive themselves, even love themselves, sometimes despite vast challenges (including abuse of one kind or another) during childhood and/or adolescence. And I’ve helped people devise cognitive tricks to shunt their trajectory away from substance use and toward more satisfying habits.

But I’ve failed a lot too. I’ve had clients I haven’t been able to help, for whom my best instincts amount to little more than a shot in the dark. With drug addiction, every failure is potentially lethal. So I figure I need to retool.

So what’s the best way to do that?

Like so many other “experts” working with people in addiction, I’m still looking for the silver bullet. Or bullets — because I can name ten schools of psychology, psychotherapy and mindfulness training off the top of my head (and some pharmaceutical approaches as well) — most of which aim to help people recover from addiction (as well as other mental health goals). And most of them do help. Some people. Sometimes.

But there seems to be a black hole in the centre of the addiction galaxy that sucks in techniques of every sort and laughingly squishes them to nothing, tosses them back down some wormhole to some parallel universe. And surely that’s because addiction boils down to a unique “thing” which is totally psychological, totally biological, and totally social. A habit in the workings of our cells, our minds, and our interpersonal relations.

(And by the way, when people ask whether addiction is psychological OR biological OR social, they’re asking the wrong question.)

But besides that, the very unique thing about addiction is that when you start to beat it, when you actually start to succeed in your recovery, then instead of a radiant glow of achievement and satisfaction (that may come later) you’re often left with an aching emptiness. And what the hell are we humans supposed to do with that?! (Mindfulness/meditation has some answers, but let’s face it, the solution isn’t obvious.)

So, I want to spend the next few posts examining some of the therapeutic techniques that are potentially effective with addiction, and try to figure out what works best, what works for whom, and how we might nudge some of these techniques so they’ll work even better. I also want to address this issue of “emptiness” head-on. It’s a biggie.

I’ll start by sharing my own plans for retooling.

Acceptance & Commitment Therapy (ACT)

ACT combines techniques from cognitive-behavioural therapy (CBT) with techniques from mindfulness/meditation. It’s oriented toward people’s basic deep-down needs — and the incredible things they do to avoid them, deny them, or satisfy them in ways that just don’t work. It’s also strategic, in that the therapist serves as a coach to try different approaches to recurring negative experiences. ACT is explicitly geared toward conscious change in how we interact with ourselves and with others.

I’ve used some ACT themes in my own work with clients. They help. But I want to get to the details. So I’ve recently enrolled in an online intensive training course. The course is taught by Steven Hayes, the founder, a guy who somehow resembles a martian, totally bald, with sea-shell ears that rise at an odd angle, but who radiates wisdom, compassion and skill. ACT is partly devised to help people with addictions. And other addiction workers (like Matt and Peter Sheath who’ve posted on this blog) see it as effective. So what’s the secret? I’ll tell you what I’m learning as I learn more.

Internal Family Systems (IFS)

IFS is a school of psychotherapy that identifies and listens to the internal voices in our heads — most obvious in addiction through the (sometimes horrendous) conversations or shouting matches between the taking-care self, the addict self, and the internal critic (how they’re often recognized and identified). The founder, a guy named Richard Schwartz, studied family systems therapy back in the 70s and began to realize that all the shit that goes on between family members is actually going on in our own heads. Sometimes almost constantly.

IFS is well-designed for dealing with addiction because addicts so frequently say “there’s a part of me that just says fuck it, I want to use” and ignores the arguments of other “parts” of the self. This division of one part of oneself from other parts just begs to be dealt with head-on. I sometimes focus on clients’ internal dialogue in my own therapy practice, though I’ve never studied IFS seriously. But now I’m reading up on IFS…to get ready. I’ll be attending a 5-day intensive workshop on IFS for people in addiction this March. I’ll let you know what I learn.

I hope visits to these and other psychotherapeutic approaches will be useful for readers who are devoted to helping people in addiction. But I also think they’ll be important for those who are struggling with their own addiction — because they can highlight what’s available from different forms of therapy and introduce powerful techniques you can use on your own.

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for addicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

The judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

……………………………………

I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

Any individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.